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Date run 10/19/2010 4:10:27P SAN J IUIN COUNTY ENVIRONMENTAL HES 'H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/19/2010 <br /> Record Selection Criteria: Facility ID FA0003795 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002818 New Owner ID <br /> Owner Name LIBERTY RURAL FIRE DIST <br /> Owner DBA LIBERTY RURAL FIRE DIST <br /> Owner Address 24124 N BRUELLA RD <br /> ACAMPO, CA 95220 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-368-0905 <br /> Mailing Address 24124 N BRUELLA RD <br /> ACAMPO, CA 95220 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003795 <br /> Facility Name LIBERTY RURAL FIRE DISTRICT <br /> Location 24124 N BRUELLA RD <br /> ACAMPO, CA 95220 <br /> Phone 209-368-0905 <br /> Mailing Address 24124 N BRUELLA RD <br /> ACAMPO, CA 95220 <br /> Care of LIBERTY RURAL FIRE DISTRICT <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 00731008 EMail : ,b I�� ` eem.•.�e� <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name S'6m 3 ty <br /> Title f l <br /> Day Phone r <br /> Night Phone f✓ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003380 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LIBERTY RURAL FIRE DISTRICT (Circle One) <br /> Account Balance as of 10/19/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0513856 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511757 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PR0507697 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231528 EE0001422-ARIS CACAPIT Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARtPR0507470 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534413 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiv <br /> REHS: i`'Z lli Date ' / `� / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />